<style>
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    #containerIntakeFormShort, #containerIntakeFormShortAutofill {
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</style>
<div class="container-short-form">
    <h4 class="title-short-form">Contact <span>Roberts Law Team</span></h4>
    <div id="containerIntakeFormShortAutofill">
        <p>
            <strong>Bold</strong> labels are required.
        </p>
        <form class="formAutoFill" id="intakeFormShortAutofill" name="intakeFormShortAutofill" action="/cgi-bin/emailservice.cgi" method="post">
            <input type="hidden" value="1384320823" name="serverTime">
            <input type="hidden" value="1658492" name="SubscriptionID">
            <input type="hidden" value="Roberts Law Group PLLC Email Inquiry, SiteDomain" name="email_subject">
            <input type="hidden" value="true" name="removeFLBranding">
            <input type="hidden" value="WuGn2jTSwSNow1tV0aR5Mab8xnrqShJ5saubCftvoXiH5RFcGMQBJvYGOqSOjzvYKGEUv202baOdKXj4ikM+1jB4pIfGdVICrDsz77yfqeFAkEw6kMndk+V9V+ci9UXZw2NtCFTplJ5iOck06the8JJPjk4fUTYp43dcZDj6hxc=" name="guid">
            <input type="hidden" value="3833155" name="wld_id">
            <input type="hidden" value="Thank-You" name="thankyouPage">
            <fieldset>
                <legend><span>Contact Information</span></legend>
                <label for="intakeFormShortName" class="formLabelHide">Name</label>
                <div class="formHighlight">
                    <input type="text" title="Name" id="intakeFormShortName" name="Name|at:name||Please enter your name.">
                </div>
                <label for="intakeFormShortEmail" class="formLabelHide"><strong>E-mail Address</strong><img width="15" height="15" src="http://video-transcripts.findlaw.com/includes/images/formRequired.gif" alt="This field is required."></label>
                <label class="formHide" for="intakeFormShortEmail"><strong>Please enter a valid e-mail address.</strong></label>
                <div class="formHighlight">
                    <input type="text" title="E-mail Address" class="validate email" id="intakeFormShortEmail" name="E-mail Address|at:email|r|Please enter a valid e-mail address." style="font-weight: bold;">
                </div>
                <label for="intakeFormShortPhone" class="formLabelHide">Phone</label>
                <div class="formHighlight">
                    <input type="text" title="Phone" id="intakeFormShortPhone" name="Phone|at:phone||Please enter a valid phone number. You may use 0-9, spaces and the ( ) - + characters.">
                </div>
                <label for="intakeFormShortMessage" class="formLabelHide">Brief description of your legal issue</label>
                <div class="formHighlight">
                    <textarea cols="15" rows="4" title="Brief description of your legal issue" id="intakeFormShortMessage" name="Brief description of your legal issue|at:message||Please describe your legal issue."></textarea>
                </div>
                <div class="formCheck">
                    <label class="formHide" for="intakeFormShortDisclaimerCheck">
                        <strong>Please verify that you have read the disclaimer.</strong>
                    </label>
                    <label for="intakeFormShortDisclaimerCheck">
                        <input type="checkbox" value="yes" class="validate checkbox" id="intakeFormShortDisclaimerCheck" name="Read disclaimer:||r|Please verify that you have read the disclaimer.">
                        <strong>I have read the <span>disclaimer.</span></strong>
                    </label>
                    <strong>
                        <a href="#intakeFormShortDisclaimer" class="intakeFormShortDisclaimerLink">disclaimer</a>.</strong>
                </div>
                <input type="hidden" value="Read disclaimer:||r|Please verify that you have read the disclaimer." name="cgi|checkboxDisclaimerIntakeFormShort" id="checkboxDisclaimerIntakeFormShort" class="intakeFormHiddenInput">
                <div id="intakeFormShortDisclaimer" style="display: none;">
                    <div>
                        <p>
                            The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.
                        </p>
                        <a rel="nofollow" href="#intakeFormShortDisclaimerCheck">close</a>
                    </div>
                </div>
            </fieldset>

            <p class="intakeFormShortPrivacy">
                <a href="/Privacy-Policy.shtml">Privacy Policy</a>
            </p>
            <input type="image" id="intakeFormShortAutofillSubmit" alt="Submit" class="submit over" value="Submit" name="Submit" src="http://www.robertslawteam.com/design/images/formSubmitShort.gif">
        </form>
    </div>
</div>